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Can Mild Restriction In Lungs Cause Breathlessness During Routine Activities?
Question: I am 45yrs, Male. BP is 150/90, weight 95kg, height 184cm, LDL cholesterol was 153, now less than 100 with medicine. Father ( now 80yrs) having some heart issues since 30+ years, but managing with medicines.
6 months back went to doctors with vague chest pains. Had some tests.
ECG says 'consider lateral ischemia'. Echo was normal (Grade 1 diastolic dysfunction). Not able to do stress test due to dizziness.
3 months back did TMT. TMT came positive - Exercise time 6.3 mins, 8 mets, shows 2.5 to 3mm ST depression. Felt very breathless but no major chest pain during test. Achieved 79% of Target heart rate. (Report attached.) Since then on medicines (Ecospirin, Sorbitrate, Dilzem, Deriphilin)
Last 2 months developed breathlessness on exertion. Did PFT (attached) - shows mild restriction (lungs). Did one more echo which was otherwise normal but had mild PAH. ECG continued to show ischemia.
Also had a sleep test 2 months back. It showed severe sleep apnea (AHI 61.7) with oxygen desaturation going down to 50% at times. (Report attached.) I have a CPAP machine but not able to fully use it.
Current Symptoms - Breathlessness on exertion, no chest pain on walking. Occasional pain in neck while walking. Chest pain early mornings while waking up. Continues for some time, then goes away. Breathless sometimes while lying down. (No swelling in ankles etc)
Questions: 1. Can my breathlessness be due to lungs or heart? Can a mild restriction in lungs cause breathlessness on routine activities. Can a mild PAH cause it. Is mild PAH a cause for worry?
2. Do I need an angiogram. Or do I need to repeat the stress test. Could it be a false positive. If false positive, could it still be false positive on repeating.
3. I have two ECGs - one Feb 2015 & other Aug 2015 attached herewith. Is there any change (better or worse) between the two. ECG in Aug 2015 shows a QTc of 529. Is this correct; is it a cause of worry?
4. What could be the cause of early morning chest pain. Could it be due to sleep apnea?
6 months back went to doctors with vague chest pains. Had some tests.
ECG says 'consider lateral ischemia'. Echo was normal (Grade 1 diastolic dysfunction). Not able to do stress test due to dizziness.
3 months back did TMT. TMT came positive - Exercise time 6.3 mins, 8 mets, shows 2.5 to 3mm ST depression. Felt very breathless but no major chest pain during test. Achieved 79% of Target heart rate. (Report attached.) Since then on medicines (Ecospirin, Sorbitrate, Dilzem, Deriphilin)
Last 2 months developed breathlessness on exertion. Did PFT (attached) - shows mild restriction (lungs). Did one more echo which was otherwise normal but had mild PAH. ECG continued to show ischemia.
Also had a sleep test 2 months back. It showed severe sleep apnea (AHI 61.7) with oxygen desaturation going down to 50% at times. (Report attached.) I have a CPAP machine but not able to fully use it.
Current Symptoms - Breathlessness on exertion, no chest pain on walking. Occasional pain in neck while walking. Chest pain early mornings while waking up. Continues for some time, then goes away. Breathless sometimes while lying down. (No swelling in ankles etc)
Questions: 1. Can my breathlessness be due to lungs or heart? Can a mild restriction in lungs cause breathlessness on routine activities. Can a mild PAH cause it. Is mild PAH a cause for worry?
2. Do I need an angiogram. Or do I need to repeat the stress test. Could it be a false positive. If false positive, could it still be false positive on repeating.
3. I have two ECGs - one Feb 2015 & other Aug 2015 attached herewith. Is there any change (better or worse) between the two. ECG in Aug 2015 shows a QTc of 529. Is this correct; is it a cause of worry?
4. What could be the cause of early morning chest pain. Could it be due to sleep apnea?
Brief Answer:
You should get Coronary angiography done
Detailed Answer:
hello,
I am Dr.Rajesh Teli,MD.
I have gone through your query and investigations.
Thanks for using HCM.
I shall answer your quesiton in order you asked.
1.Your breathlessness is contributed by both heart and lungs collectively.As you have rightly thought that mild restriction will not produce so much breathlessness hence contribution of heart has to be considered more.(Mild PAH also would not cause such breathlessness.)
2.The detail report of your stress test mentions that you had chest pain and the test was terminated on your request,there was ST depression in infeorlateral leads at peak exercise.This points towards possibility of blocks in arteries of heart and is likely cause of your chest pain and breathlessness on exertion.You should not repeat stress test ,instead you should get coronary angiography done.As it is most definitive test to assess presence and severity of blocks in arteries of heart.
3.Both your ECGs are showing dynamic changes which points towards possibility of blocks in coronary arteries.
4.Sleep apnoea will not lead to chest pain however you should use CPAP machine which will improve your BP control and prevent deterioration of symptoms of Blockage in coronaries.
Your early morning chest pain may be angina and exerional neck pain may also be feature of angina.
I suggest you to get Coronary angiography done,This will immensely help us to decide further line of treatment.If it is normal then we have to focus only on lungs and sleep apnoea.If abnormal ,depending on severity of block,you may need some intervention.
Meanwhile continue same line of treatment along with CPAP.We should rule out or treat coronary blocks as early as possible because there is risk of sudden deterioration of health if not properly evaluated and treated.NO harm if Angio is normal,
so please go for Coronary angiography and inform me report so i can guide you further
MY best wishes
Dr.Rajesh Teli,MD.
You should get Coronary angiography done
Detailed Answer:
hello,
I am Dr.Rajesh Teli,MD.
I have gone through your query and investigations.
Thanks for using HCM.
I shall answer your quesiton in order you asked.
1.Your breathlessness is contributed by both heart and lungs collectively.As you have rightly thought that mild restriction will not produce so much breathlessness hence contribution of heart has to be considered more.(Mild PAH also would not cause such breathlessness.)
2.The detail report of your stress test mentions that you had chest pain and the test was terminated on your request,there was ST depression in infeorlateral leads at peak exercise.This points towards possibility of blocks in arteries of heart and is likely cause of your chest pain and breathlessness on exertion.You should not repeat stress test ,instead you should get coronary angiography done.As it is most definitive test to assess presence and severity of blocks in arteries of heart.
3.Both your ECGs are showing dynamic changes which points towards possibility of blocks in coronary arteries.
4.Sleep apnoea will not lead to chest pain however you should use CPAP machine which will improve your BP control and prevent deterioration of symptoms of Blockage in coronaries.
Your early morning chest pain may be angina and exerional neck pain may also be feature of angina.
I suggest you to get Coronary angiography done,This will immensely help us to decide further line of treatment.If it is normal then we have to focus only on lungs and sleep apnoea.If abnormal ,depending on severity of block,you may need some intervention.
Meanwhile continue same line of treatment along with CPAP.We should rule out or treat coronary blocks as early as possible because there is risk of sudden deterioration of health if not properly evaluated and treated.NO harm if Angio is normal,
so please go for Coronary angiography and inform me report so i can guide you further
MY best wishes
Dr.Rajesh Teli,MD.
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Dear Doctor
Thank you for your detailed and clear answer. I would like to ask the following queries:
1. Having seen my TMT which was attached, could you please tell me whether it was 'mildly positive', 'moderately positive', or 'strongly positive'. Am asking this because I understand stress tests are sometimes 'false positive'
2. Would there be any harm (i.e. danger) in my repeating the stress test before undergoing an (invasive) angiogram. This is basically to help me understand if the position has improved (with medicine for 3 months) or worsened. Also to see if it was a 'false positive' by chance.
3. I understand both the ECGs showed changes. I would like to know if there has been any deterioration from the first to the second one. (The first one was Feb, second one Aug - the one with the QTc 451 is first one, QTc 529 is 2nd one.)
4. One doctor told me that since I performed up to 6.3 minutes on the treadmill, I am not likely to have a serious block. It this correct in your opinion.
5. For an angiogram, I understand that if blocks are found it may lead to intervention like angioplasty etc, for which I need time to get prepared both in terms of adjusting work schedules and financials (I am self-employed). Is there any danger in leaving this over for another month or two. Of course if the situation warrants I should get ready to do it earlier. I request your opinion on this.
6. Based on your expert opinion (having seen thousands of cases like mine) of my reports, do you think that there is a strong chance of my angiogram showing significant blocks. I am sorry, I realise this is not a fair question to ask, am asking only because I need to get prepared personally, work-wise and financially for possible cardiac interventions if needed.
7. Is my mild PAH a cause of worry. Also the QTC of 529.
Sorry for burdening you with so many questions. I and my family are naturally a bit worried about this.
Regards and many thanks
Thank you for your detailed and clear answer. I would like to ask the following queries:
1. Having seen my TMT which was attached, could you please tell me whether it was 'mildly positive', 'moderately positive', or 'strongly positive'. Am asking this because I understand stress tests are sometimes 'false positive'
2. Would there be any harm (i.e. danger) in my repeating the stress test before undergoing an (invasive) angiogram. This is basically to help me understand if the position has improved (with medicine for 3 months) or worsened. Also to see if it was a 'false positive' by chance.
3. I understand both the ECGs showed changes. I would like to know if there has been any deterioration from the first to the second one. (The first one was Feb, second one Aug - the one with the QTc 451 is first one, QTc 529 is 2nd one.)
4. One doctor told me that since I performed up to 6.3 minutes on the treadmill, I am not likely to have a serious block. It this correct in your opinion.
5. For an angiogram, I understand that if blocks are found it may lead to intervention like angioplasty etc, for which I need time to get prepared both in terms of adjusting work schedules and financials (I am self-employed). Is there any danger in leaving this over for another month or two. Of course if the situation warrants I should get ready to do it earlier. I request your opinion on this.
6. Based on your expert opinion (having seen thousands of cases like mine) of my reports, do you think that there is a strong chance of my angiogram showing significant blocks. I am sorry, I realise this is not a fair question to ask, am asking only because I need to get prepared personally, work-wise and financially for possible cardiac interventions if needed.
7. Is my mild PAH a cause of worry. Also the QTC of 529.
Sorry for burdening you with so many questions. I and my family are naturally a bit worried about this.
Regards and many thanks
Brief Answer:
you should rely on specific test i.e.Angiography.
Detailed Answer:
hello,
I can understand your anxiety and i m quite happy to answer all your questions.I always tell my patients that it is my duty to explain in detail smalles part of management.So don't worry for any number of questions!
First i shall explain to you about TMT ,
we usually carry out TMT to know whether symptoms of a patient are likely to be angina or not ,to predict risk of heart attack in near future and to know exercise tolerance of patient.
we basically observe 3 parameters during the test
1.Development of symptoms viz.chest pain,uneasyness and any unusual symptom.
2.Depression of ST segment in consecutive leads or elevation of ST segment.(this is compared on baseline level and is considered abnormal)
3.Response of blood pressure.
There are basically 5 stages of 3 min each.
Now mild ,moderate and severe are loose terms and grossly i can say earlier the symptoms and ST depression more severe the abnormality.
In your case you exercise till beginning of 3rd stage so exercise tolerance wise is good but you had chest pain and ST depression along with shooting of BP at peak exercise Your BP was 200/100 .It was at peak exercise of 6 min and 36 sec.
So it should be considered abnormal and moderately positive.As i mentioned earlier that specificity of TMT is 70% and if you are suspecting false positive then there is no point in repeating it but to go for more definitive test.
As you had symptoms were in 3rd stage and if right now you have no symptoms then you can wait with medicines.But heart is very very unpredictable organ.so better to get CAG done.Decision of waiting for intervention can be made after seeing severity of blockages.
QTC is affected by many medicines and whenever there is prolongation doctor should avoid certain medicines which your doctor will ofcourse know ,otherwise this abnormality is not contributing to diagnosis of symptoms.so in my opinion CAG is better option.PAH is mild and we have to focus on sleep apnoea and restriction of lung ,otherwise not to worry for PAH as on now.
Regarding your Financial part i would like to inform you that there are many hospitals in XXXXXXX offering CAG at low cost around Rs.Five thousand XXXXXXX XXXXXXX XXXXXXX hospital at puttaparthi and banglore offer it at free of cost.I would be happy to guide you in this respect also.Do you have health insurance ?
My best wishes
DR.Rajesh Teli,MD
you should rely on specific test i.e.Angiography.
Detailed Answer:
hello,
I can understand your anxiety and i m quite happy to answer all your questions.I always tell my patients that it is my duty to explain in detail smalles part of management.So don't worry for any number of questions!
First i shall explain to you about TMT ,
we usually carry out TMT to know whether symptoms of a patient are likely to be angina or not ,to predict risk of heart attack in near future and to know exercise tolerance of patient.
we basically observe 3 parameters during the test
1.Development of symptoms viz.chest pain,uneasyness and any unusual symptom.
2.Depression of ST segment in consecutive leads or elevation of ST segment.(this is compared on baseline level and is considered abnormal)
3.Response of blood pressure.
There are basically 5 stages of 3 min each.
Now mild ,moderate and severe are loose terms and grossly i can say earlier the symptoms and ST depression more severe the abnormality.
In your case you exercise till beginning of 3rd stage so exercise tolerance wise is good but you had chest pain and ST depression along with shooting of BP at peak exercise Your BP was 200/100 .It was at peak exercise of 6 min and 36 sec.
So it should be considered abnormal and moderately positive.As i mentioned earlier that specificity of TMT is 70% and if you are suspecting false positive then there is no point in repeating it but to go for more definitive test.
As you had symptoms were in 3rd stage and if right now you have no symptoms then you can wait with medicines.But heart is very very unpredictable organ.so better to get CAG done.Decision of waiting for intervention can be made after seeing severity of blockages.
QTC is affected by many medicines and whenever there is prolongation doctor should avoid certain medicines which your doctor will ofcourse know ,otherwise this abnormality is not contributing to diagnosis of symptoms.so in my opinion CAG is better option.PAH is mild and we have to focus on sleep apnoea and restriction of lung ,otherwise not to worry for PAH as on now.
Regarding your Financial part i would like to inform you that there are many hospitals in XXXXXXX offering CAG at low cost around Rs.Five thousand XXXXXXX XXXXXXX XXXXXXX hospital at puttaparthi and banglore offer it at free of cost.I would be happy to guide you in this respect also.Do you have health insurance ?
My best wishes
DR.Rajesh Teli,MD
Above answer was peer-reviewed by :
Dr. Raju A.T
Dear Doctor
Thanks for the detailed reply. It is really helpful to have our doubts resolved by kind and understanding doctors like you.
Based on your detailed explanations, I understand an angiogram is best for me now. (I have current symptoms of breathlessness and a constriction in my neck while walking. Breathlessness is while any walking, neck pain comes sometimes.) Most probably I may schedule an angiogram in September.
Just wondered if a CT angiogram is useful. Also was planning to repeat stress test as part of a master health check-up package; is there any danger in this because I may have a block.
Also many thanks regarding the guidance on low-cost angiogram. Actually by God' grace, I have no problem in affording the angiogram itself; I am only worried if it leads to angioplasty etc which I understand may cost more than a lakh of rupees. That is why I was asking what are the chances of this (i.e. bigger blocks) based on my reports.
(My FIL had an angiogram. Doctor had said, it would only be a routine test; but while doing it, they came and told us that he needs angioplasty, preferably immediately (i.e. while the catheter is still in place) and we had to decide in a few minutes; we had to run about and arrange for 1.5 lakhs for that at short notice. We were totally unprepared for that. This is what I am worried about. So I am wondering what are the chances of my having such a severe block as to need this angioplasty.) Whatever the situation if we know well in advance we can be better prepared.
Thanks & Regards.
Thanks for the detailed reply. It is really helpful to have our doubts resolved by kind and understanding doctors like you.
Based on your detailed explanations, I understand an angiogram is best for me now. (I have current symptoms of breathlessness and a constriction in my neck while walking. Breathlessness is while any walking, neck pain comes sometimes.) Most probably I may schedule an angiogram in September.
Just wondered if a CT angiogram is useful. Also was planning to repeat stress test as part of a master health check-up package; is there any danger in this because I may have a block.
Also many thanks regarding the guidance on low-cost angiogram. Actually by God' grace, I have no problem in affording the angiogram itself; I am only worried if it leads to angioplasty etc which I understand may cost more than a lakh of rupees. That is why I was asking what are the chances of this (i.e. bigger blocks) based on my reports.
(My FIL had an angiogram. Doctor had said, it would only be a routine test; but while doing it, they came and told us that he needs angioplasty, preferably immediately (i.e. while the catheter is still in place) and we had to decide in a few minutes; we had to run about and arrange for 1.5 lakhs for that at short notice. We were totally unprepared for that. This is what I am worried about. So I am wondering what are the chances of my having such a severe block as to need this angioplasty.) Whatever the situation if we know well in advance we can be better prepared.
Thanks & Regards.
Brief Answer:
CT angiography is not advisable for you
Detailed Answer:
hello,
I have gone through your query.CT angiography has very high negative predictive value hence if it is normal then one can put a full stop for blockage in coronaries.But if there are some blocks then its reliability is not perfect to plan intervention and hence it must be followed by routine angiography for planning line of treatment.I only advise CT angio to those of my patients who have least probability of blockage where our goal is to rule out Blocks.In your case your constricting pain in neck is quite likely to be angina and i request you not to repeat TMT but to go for angiography.Because there is risk of heart attack 1 in 10,000 patients who have exertional symptoms.rarely it may happen that such patients need immediate angiography right from TMT room !
so better avoid it.
I also suggest you to go to the cardiologist whom you trust and keep full faith ,Go prepared with fund of angioplasty ,as the first step of angiography and angioplasty is same.Though you may always ask and good cardiologist will give you time to plan for angioplasty after some time ,if there are no critical blocks.
In your case i anticipate that there will be blocks but may not be such critical requiring immediate plasty,However final decision can me made only after angiography.
My best wishes
Dr.Teli.
CT angiography is not advisable for you
Detailed Answer:
hello,
I have gone through your query.CT angiography has very high negative predictive value hence if it is normal then one can put a full stop for blockage in coronaries.But if there are some blocks then its reliability is not perfect to plan intervention and hence it must be followed by routine angiography for planning line of treatment.I only advise CT angio to those of my patients who have least probability of blockage where our goal is to rule out Blocks.In your case your constricting pain in neck is quite likely to be angina and i request you not to repeat TMT but to go for angiography.Because there is risk of heart attack 1 in 10,000 patients who have exertional symptoms.rarely it may happen that such patients need immediate angiography right from TMT room !
so better avoid it.
I also suggest you to go to the cardiologist whom you trust and keep full faith ,Go prepared with fund of angioplasty ,as the first step of angiography and angioplasty is same.Though you may always ask and good cardiologist will give you time to plan for angioplasty after some time ,if there are no critical blocks.
In your case i anticipate that there will be blocks but may not be such critical requiring immediate plasty,However final decision can me made only after angiography.
My best wishes
Dr.Teli.
Above answer was peer-reviewed by :
Dr. Prasad
Dear Doctor
Many thanks for the very clear and detailed reply. Really appreciate that a top cardiologist like you is able to spare so much time for me. You have cleared most of my doubts. As of now I am planning to have the angiography in September.
May I trouble you with a last few questions?
1. My neck pain comes sometimes while walking, not always. Is this still suggestive of angina? Also early morning chest pain sometimes, comes without exertion. Can it be angina?
2. After Angiogram, suppose it comes normal, i.e. no blocks; then what would be my heart status i.e. would I still need to take the medicines like ecospirin, sorbitrate & dilzem? Would this mean that stress test was false positive? Would I then need any follow-ups yearly.
3. If Angioplasty is needed and done, how long would I need to rest i.e. take leave from office work?
4. Is it possible that my symptoms are due to anxiety? Can anxiety alone cause the ECG changes and make TMT positive?
5. Until I do angiogram i.e. next month, any precautions I need to take?
Thank you, doctor.
Warm Regards.
Many thanks for the very clear and detailed reply. Really appreciate that a top cardiologist like you is able to spare so much time for me. You have cleared most of my doubts. As of now I am planning to have the angiography in September.
May I trouble you with a last few questions?
1. My neck pain comes sometimes while walking, not always. Is this still suggestive of angina? Also early morning chest pain sometimes, comes without exertion. Can it be angina?
2. After Angiogram, suppose it comes normal, i.e. no blocks; then what would be my heart status i.e. would I still need to take the medicines like ecospirin, sorbitrate & dilzem? Would this mean that stress test was false positive? Would I then need any follow-ups yearly.
3. If Angioplasty is needed and done, how long would I need to rest i.e. take leave from office work?
4. Is it possible that my symptoms are due to anxiety? Can anxiety alone cause the ECG changes and make TMT positive?
5. Until I do angiogram i.e. next month, any precautions I need to take?
Thank you, doctor.
Warm Regards.
Brief Answer:
Chest pain may be due to other cause if angiogram is normal
Detailed Answer:
Hello,
I have gone through your query.
1.As many as 10 to 15 % of patients have atypical angina that means they may not have classical chest pain ,But by and large any pain which comes up with exertion and is relieved by rest should be considered as angina unless proved otherwise.In your case still it can be cervical pain ,but we have to rule out angina first.Your chest pain which is different from neck pain and is not related to exertion may be due to acid reflux and may need PPI group of medicines. But as I mentioned earlier you have to rule out heart condition.
2.If your angiogram turns out to be normal then ecosprin, sorbitrate and dilzem may be stopped. And TMT may be considered as false positive.And you may need routine work up every two years.
3.If you need angioplasty you will have to be in hospital for 2 to 3 days ,and you can resume office within a week(Inclusive of hospitalisation).
4.Anxiety will not produce false positive TMT.
5.Till angiogram is done, avoid undue exertion, stress and take regular medicines.
I would be keen to know your Angiogram report
My best wishes
Dr.Teli.
Chest pain may be due to other cause if angiogram is normal
Detailed Answer:
Hello,
I have gone through your query.
1.As many as 10 to 15 % of patients have atypical angina that means they may not have classical chest pain ,But by and large any pain which comes up with exertion and is relieved by rest should be considered as angina unless proved otherwise.In your case still it can be cervical pain ,but we have to rule out angina first.Your chest pain which is different from neck pain and is not related to exertion may be due to acid reflux and may need PPI group of medicines. But as I mentioned earlier you have to rule out heart condition.
2.If your angiogram turns out to be normal then ecosprin, sorbitrate and dilzem may be stopped. And TMT may be considered as false positive.And you may need routine work up every two years.
3.If you need angioplasty you will have to be in hospital for 2 to 3 days ,and you can resume office within a week(Inclusive of hospitalisation).
4.Anxiety will not produce false positive TMT.
5.Till angiogram is done, avoid undue exertion, stress and take regular medicines.
I would be keen to know your Angiogram report
My best wishes
Dr.Teli.
Note: For further queries related to coronary artery disease and prevention, click here.
Above answer was peer-reviewed by :
Dr. Vaishalee Punj
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